Bowel Dysfunction Overview:
Bowel dysfunction is a relatively common symptom of people afflicted with multiple sclerosis (MS).
Multiple Sclerosis (MS) is an autoimmune disorder of the central nervous system (brain, brain stem and spinal cord). Nerve cells are surrounded by an insulating sheath made of a fatty substance called myelin that helps to transmit nerve impulses. In multiple sclerosis (MS), this myelin sheath is inflamed or damaged as the immune system attacks the nerves. This disrupts or slows nerve impulses and causes nerves to malfunction. The result is scarring (sclerosis) occurring in brain and spinal cord. These areas of myelin damage and scarring are called multiple sclerosis (MS) plaques. The disease periodically flares up with episodes of increased symptoms.
There are many reasons why a person may experience changes in bowel movement patterns. People with multiple sclerosis (MS) experience higher rates of dysfunction some reasons being demyelination of the central nervous system (CNS) resulting in slowed transit times of nervous system electrical messages, muscle weakness, fatigue, lack of exercise and medications.
Constipation is the most frequently reported problem. The definition of constipation is infrequent (2 bowel movements or less per week) or difficult elimination of stool. Slowed transit time, altered fecal composition, decreased ability to expel feces and altered ability to acknowledge the urge to defecate may all cause constipation.
Diarrhea is less common than constipation and may even be a result of constipation. The definition of diarrhea is abnormal fluid stools. If hardened stool is retained, diarrhea may occur around the mass.
Fecal incontinence is the involuntary passage of stool. Contributing factors include: sphincter dysfunction, sensory loss in the rectum, medications and dietary problems.
One study involving 77 positively diagnosed multiple sclerosis patients showed that bowel problems are in no way associated with bladder dysfunction, patient age, duration of the disease or the level of disability currently existing in each patient.
The most frustrating and often depressive related symptom of bowel dysfunction is fecal incontinence or involuntary bowel movements. MS interrupts or slows the electrical signals to and from the central nervous system (brain, brain stem and spinal cord) and electrical impulses are what control the muscles that are involved in bowel movements.
It has been said that up to 50% of people afflicted with multiple sclerosis (MS) suffer from some form of bowel dysfunction along the course of the disease.
Bowel dysfunction may also aggravate other symptoms such as spasticity or bladder dysfunction but it is thought to not be directly associated with either.
Bowel Dysfunction Diagnosis:
Bowel dysfunction can be the result of mixed factors including medications, food intake, fluid intake, MS itself and other factors. It is important to keep a record of your multiple sclerosis as all factors help your health care team navigate through symptoms caused by MS and solutions to those symptoms.
A health care professional will review much of the following and more:
- Frequency and type of bowel movements
- Usual time of day pattern
- Reliance on laxatives or enemas
- Current medications
- Comorbid medical conditions that may affect medications
- MS disease history
- Recent exacerbation or flare-ups of MS
- Dietary intake
- Fluid intake
- And more…
Bowel Dysfunction Treatment:
Treatment of bowel dysfunction includes patient assessment, interventions, medications, bowel reflexes, and colostomy. Treatments will vary from individual to individual and should be discussed with a primary care provider. In addition, a change in bowel patterns may not be due to multiple sclerosis.
It is important that a full evaluation be considered for each case.
General interventions in bowel dysfunction may include:
- Education about the causes of bowel dysfunction.
- Encouraging dietary changes to include more fiber and fluid.
- Consulting with your health care provider to adjust medication regimens that may be contributing to bowel dysfunction.
- Establishing a regular bowel routine, individualized to the patient.
- Encouraging regular physical activity.
Bowel management goals are to establish a comfortable bowel movement every day, every other day or every two days.
Regular bowel movements require 1 ½ to 2 quarts a day of fluid, 20 to 30 grams a day of fiber as well as physical activity.
For example, One-third of a cup of Fiber One®, All Bran® or 100% Bran Buds® gives you half the fiber you need for the day.
Greasy, spicy foods or food intolerance such as lactose intolerance can result in loose stools and may result in involuntary bowel movements as well.
Some Management Suggestions:
- Eat regularly for regular bowel habits.
- Maintain regular mealtimes.
- Plan for a bowel movement each day about ½ hour after eating or drinking something warm (bowel activity is naturally increased at this time).
- Sit on the toilet about 10 minutes, and try to have a BM.
- You may want to gently rock back and forth on the toilet. If nothing happens, leave the bathroom and try again later.
- Use a suppository to help stimulate bowel activity. (It takes about 20 minutes for a suppository to work.)
- Occasionally, it might be helpful to take milk of magnesia or citrate of magnesia to stimulate bowel activity.
- It may take two to three months to establish a regular bowel regimen.
- Changes in the bowel program may be needed, but changes should be one change at a time to measure effectiveness.
- Allow a 5 to 7 day trial period for each bowel program intervention.
- Positioning aids help with elimination. An upright position allows gravity to assist in peristalsis and stool expulsion.
- Having knees higher than the hips and feet flat on a surface (eg. a small step-stool might work well) helps increase abdominal pressure to facilitate defecation. It also straightens the angle between the rectum and the anal canal to promote rectal emptying.
- Abdominal massage. Massage the right groin upward, across and down to left groin.
- Breathing techniques can increase intra-abdominal pressure. By taking slow, deep breaths combined with abdominal muscle contractions (or leaning forward) help increase rectal emptying.
Below is a guide for medication dosages that are commonly used for bowel problems. This is only a guideline, and should not be used until after a full patient assessment and disease evaluation is completed by a health care provider. The following list of recommendations will vary from patient to patient. For specific information on dosing refer to the pharmaceutical guidelines.
- Glycerin – daily or every other day
- Dulcolax – daily or every other day
- Mini-enemas – daily or every other day
- Bulk forming agents:
- Metamucil – 1 to 2 teaspoons daily, mixed in a glass of water or juice and followed by another 8 ounce glass of liquid.
- Fibercon – 2 tablets, 1 to 4 times per day. Follow with this dose with an 8 ounce glass of water.
- Citrucel – 1 tablespoon, 1 to 3 times daily mixed in 8 ounces of juice or water.
- Stool softeners:
- Dialose – 50 to 200 mg daily
- Colace – 100 to 400 mg daily
- Surfak – 1 every morning
- Softeners with a laxative component:
- Dialose Plus – 1 daily
- Pericolace – 1 to 2 every night
- Senokot – 0.5 to 2 grams once or twice per day
- Senna – 2 pills 1 to 2 times per day
- Dulcolax – 10 to 30 mg at bedtime
- Osmotic laxatives:
- Sorbitol – 1 to 2 grams per kilogram of body weight daily
- Lactulose – 30 ml every night
- Milk of Magnesia – 15 to 30 ml daily as needed
Medications and laxatives are oral stimulants that result in a chemical irritant to the bowel. They should be used cautiously as should large volume enema procedures as these over time can become dangerous and result in other health complications.
Before undertaking any medications related to bowel dysfunction first consult with your health care team. This is very important with people afflicted with multiple sclerosis as effective symptoms management is more complex that is the case for healthy people having some form of bowel dysfunction.
Colostomy is considered after the above interventions are ineffective in developing normal bowel function. A colostomy is a surgical operation that creates an opening from the colon to the surface of the body to function as an anus. The fecal matter is deposited in a bag that is on the outside of the body. This is not an uncommon medical procedure for some people with severe disease and/or slowed transit time. A colostomy can actually provide the much needed relief for patients and simplify care by caregivers.
Bowel dysfunction affects many people afflicted with multiple sclerosis and as the disease progresses odds are at some stage bowel irregularities may appear. It is important before getting to that stage that lifestyle changes in fluid intake, dietary intake and seeking regularity in bowel management be undertaken. There are many options to help deal with bowel dysfunction and changes in lifestyle happening before any particular influences due to MS can help both now and future bowel regularity.